5828 North Clark Street, Chicago, IL 60660 / For Office Use Only: / Initial / Reapply
(773) 334-2300 phone / (773) 334-8228 fax / Home Study Services Only
/ http://adoptioncenterofillinois.org / Expedited Home Study Service
ADOPTION APPLICATION FORM / Domestic Programs
We will hold this information in strict confidence.
Name / Applicant 1 / Applicant 2Last / Last
First / First
Middle / Middle
Name Used / Name Used
(Mr., Mrs., Ms., Dr.) / (Mr., Mrs., Ms., Dr.)
Social Security Number / Social Security Number
Residence / Number and Street
City / State / Zip
Home Phone
Work Phone / Work Phone
Cell Phone / Cell Phone
E-Mail / E-Mail
Type of Residence
# of Bedrooms / How long at this address
Please list the number and kind of any pets
Birth / Date / Place / Date / Place
Religion
Marriage / Date / City / State
Previous Marriage Date / Previous Marriage Date
Termination Date / Death
Divorce / Termination Date / Death
Divorce
Previous Marriage Date / Previous Marriage Date
Termination Date / Death
Divorce / Termination Date / Death
Divorce
Previous Marriage Date / Previous Marriage Date
Termination Date / Death
Divorce / Termination Date / Death
Divorce
Present Employment
Other Income / Occupation / Occupation
Employer / Employer
Street Address / Street Address
City, State, Zip / City, State, Zip
How Long Employed / How Long Employed
Hours Worked Per Week / Hours Worked Per Week
Annual Salary / Annual Salary
Amount & Source / Amount & Source
Effective April 2017 / Page 1
Physical Description / Height / Weight / Height / WeightEthnicity/Race / Ethnicity/Race
Education / Highest Degree Received / Highest Degree Received
Last School Attended / Last School Attended
Children Living in the Home / Name
Birth Date / Sex Male Female
Biological or Adopted
Name
Birth Date / Sex Male Female
Biological or Adopted
Name
Birth Date / Sex Male Female
Biological or Adopted
Other Adults Living in the Home / Name
Relationship to You / Social Security Number
Birth Date
Name
Relationship to You / Social Security Number
Birth Date
Children Not Living with You / Name / Birth Date
/ Circumstances
Name / Birth Date / Circumstances
Name / Birth Date / Circumstances
Assets / Life Insurance Amount / Amount in Savings
Value of Real Estate / Other Income
Other Assets
Liabilities / Mortgages
Other
Unusual Expenses
Have you ever filed for bankruptcy? YES or NO
Have you ever had a foreclosure on your property? YES or NO
If yes? When
Other Agencies, Attorneys & Adoption Resources
We support potential AP’s in pursuing a number of options. Please list the other resources with whom you are currently working.
By providing this information you are granting us permission to contact these entities as part of the application process. Please initial below to confirm this understanding:
______/______ / 1. Name / Contact Person
Address
Phone / Fax
2. Name / Contact Person
Address
Phone / Fax
3. Name / Contact Person
Address
Phone / Fax
How Did You Hear About our Agency?
Did you attend a Program Introduction? If yes, what date? If you previously worked with us, please summarize.
Effective April 2017 / Page 6
For All Applicants / Check the ethnic backgrounds that you would consider adopting fromCaucasian Latino African American Asian
Caucasian/Latino Caucasian/African American Caucasian/Asian
Other
From what country do you wish to adopt?
What is the age range of the child you wish to adopt?
How many children do you hope to adopt at one time?
List the names and dates of any adoption seminars, classes or presentations that you have attended
Related Reference
Relatives who know about your decision to adopt / 1. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
2. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
Personal Reference
People (not related to you) who have known you well and on a personal basis for at least three years / 1. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
2. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
3. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
4. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
5. Name / Email
Address
City / State / Zip
Home Phone / Work Phone
Effective April 2017 / Page 6
In narrative form, in the space below, please briefly describe the history of your decision to adopt and your thoughts about the adoption process.
Applications will be processed upon receipt of the following:
1] This fully completed application;
2] One recent photograph of applicant(s) (for internal use only); and,
3] The appropriate fee as indicated below. Please make checks payable to Adoption Center of Illinois.
Note: If you prefer to pay with a credit card, there will be an additional 3.5% added for each transaction.
Once these materials are received, we will begin reviewing your application. We will contact some of the references you provided and contact you to arrange for an initial assessment interview. We reserve the right to decide whether or not to continue the adoption process with you based on a review of this application, conversations with your references, and impressions obtained during subsequent interview and home visit(s). Please be advised that completion of the home study process does not guarantee that you will be approved to adopt by our agency. Also, we do not guarantee that if you are approved as potential adoptive parents that our agency will ever be able to place a child with you. You may participate in more than one program at a time and, should you be approved, have our support in pursuing any other legal adoption. Whether you wish to participate in one program or more than one program, to start the process please submit this application and the fee that corresponds to the services you wish to obtain.
Please check the appropriate box(s) below to indicate the program you are applying to and the fee you are submitting:
Ö /Program
/Fee
Domestic Programs – Phase ITAP Program Home Study Only Waiting Child Program Undecided
Includes Home Study, education/training, up to (4) post visits for one child (additional posts will be billed at $300 per visit), court report and other comprehensive services for applicants working with out-of-state agencies / $4,000
International Home Study Only Program
Includes Home Study, education/training, up to (4) post visits for one child (additional posts will be billed at $300 per visit), court report and other comprehensive services for applicants working with out-of-state agencies / $4,000Home Study Re-Application for previous Clients
i.e.: 2nd, 3rd, etc. adoption, to any program noted above;
Up to (4) post visits covered for one child (additional posts will be billed at $300 per visit)
/ $3,500Hague Outgoing Case Management & Supervision Services
/ $2,500Primary Provider Services – Phase I
/ $1,000Expedited Fee (Additional fee to any program noted above for emergency situations only)
/ $750Other:
/ $Note: If you prefer to pay with a credit card, there will be an additional 3.5% added for each transaction.
Under normal circumstances and predicated on your willingness to be available for meetings, education classes and interviews, the initial interview, Home Study and evaluation process will be completed within approximately 90 days from the date our agency receives this application form and other materials as specified above. Please be advised that by submitting and signing this application and paying associated fees, you are verifying your understanding and agreement that the fee(s) paid along with this application are non-refundable unless they meet the criteria set forth on page 6 of this application.
By signing this application below you are acknowledging that you aware that it is your responsibility to review and ask questions about the “Comprehensive Schedule of Fees” that is found on-line at http://adoptioncenterofillinois.org, and that you understand the fees associated with Home Study Updates, additional post placement visits if required, converting a Home Study from Domestic to International, International to Domestic, or from one country to another, etc.
PLEASE NOTE: An individual with a history of certain types of criminal convictions may be ineligible to adopt, either because they are unable to obtain a Foster Family Home License under Illinois DCFS regulations, or because they are ineligible to adopt under the law or under the rules of a foreign country. Even if our agency believes that such an individual/couple may otherwise be qualified to adopt, they will not be able to adopt. If you have a criminal history/arrest record, you may want to consult with independent legal counsel before submitting this application. You are required to inform our agency of any arrest/criminal history, regardless of the outcome, regardless if you believe it was expunged, and failure to do so would be grounds to deny approval.
Signature / SignatureDate / Date
Adoption Center of Illinois at Family Resource Center’s Refund Policy
In the spirit of transparency, and in order to avoid any confusion, our agency wants applicants to know what fees are refundable and under what circumstances. Unless otherwise stated below, all fees paid to our agency are non-refundable.
I. Phase I or Home Study Fee
A portion of the Phase I or Home Study Fee is refundable under the following circumstances:
A] If an applicant submits an application to our agency and withdraws[1] it within 72 hours of the time it has been received by our agency, all but $250 of the Phase I or Home Study Fee is refundable.
B] If an applicant submits an application to our agency and withdraws1 it within 21 days of the time it has been received by our agency, all but $1,000 of the Phase I or Home Study Fee is refundable.
C] There shall be no refund of the Phase I or Home Study Fee once a worker enters an applicant’s home and begins an in-home visit and interview even if this interview and visit begins prior to the 21 day period referenced above in section [B].
II. TAP Program Placement Fee
The TAP Program Placement Fee is refundable under the following circumstances:
In legal risk situations involving unknown putative fathers, the actual amount of the placement fee paid by an adoptive parent(s) will be fully refunded by Adoption Center of Illinois at Family Resource Center in the event that the adoptive placement of the child is reversed prior to the finalization of the adoption, due to (1) a successful legal challenge brought by a putative/biological father and (2) loss of custody of the child by the adoptive parent(s). This refund will be made by our agency to the adoptive parent(s) within 60 days after both the entry of the final court order and the return or surrender of the child to Adoption Center of Illinois at Family Resource Center or the putative/biological father. The 60 day period will begin after the second of the aforementioned events occurs.
III. Agency Assisted Placement Program “Expense Fund”
This section only applies to participants in the Agency-Assisted Adoption Placement (AAP) Program. The unused portion of an applicant’s “Expense Fund” in the AAP Program is refundable as per the terms set forth in the AAP Program Agreement entered into between Adoption Center of Illinois at Family Resource Center and program participants/applicants and signed by the applicants.
Read, understood and agreed to by:
______
Adoptive Parent Signature Date Adoptive Parent Signature Date
Effective April 2017 / Page 6
[1] An application shall be considered “withdrawn” when the applicant(s) sends an email or fax to an ACI staff member indicating their desire to withdraw their application. If applicant does not receive confirmation within 48 hours, please contact agency Associate Director.